Nurse Practitioner Kimberly Garcia and Dr. Sanjai Rao have a discussion on how they treat schizophrenia and highlight the considerations of prescribing long-acting injectables.
Sanjai Rao, MD, DFAPA: Let’s switch gears a little and talk more about the specific treatment for schizophrenia. I thought we could start by talking about treatment algorithms for patients with schizophrenia. When you’re thinking about a patient with schizophrenia, what algorithm do you follow, or is there 1 to think about? What am I going to treat this patient with, and how is this going to go?
Kimberly Garcia, DNP, CRNP: I do have an algorithm. As a provider, it’s interesting to observe the evolution of my algorithm. If this was 15 years ago and we were having this conversation, I’d start with 1 particular antipsychotic. If it’s not effective, then I’d increase the dose until we achieve efficacy or there are tolerability issues. If that’s still not effective in controlling their symptoms, I may add a second agent or think about combining a first- and second-generation antipsychotic.
These days, things have changed for me because I work in an environment that supports the use of long-acting injectables [LAI]. We have a whole nursing department. They administer the majority of those injections. We’ve become known in our community as a facility that offers this as a treatment option. It’s interesting how that gets communicated to other individuals. We’re often approached by patients who are interested in looking at that as a treatment option. The reason that I tend to gravitate more toward injections is, No. 1, the reality is that adherence is going to be a problem. Oftentimes, poor adherence is going to lead to relapse, which is going to lead to hospitalization, incarceration, or other very negative outcomes for the patient.
What I would do now is start them on an oral antipsychotic to begin. I try to identify 1 that has fewer adverse effects than the others. I provide as much education as I can in regard to metabolic syndrome, the need for AIMS [Abnormal Involuntary Movement Scale] testing and tardive [dyskinesia] symptoms, for example. Of course, that also scares patients, but at least allow them the sufficient knowledge to be able to make informed decisions.
However, it’s not long in the treatment trajectory before I start presenting the option to them. If they were interested, they could come into the facility and could receive 1 of the long-acting injectables. We talk about what that process looks like.
Sanjai Rao, MD, DFAPA: Is the potential availability of an LAI 1 of the things you think about when you’re selecting that initial agent for them?
Kimberly Garcia, DNP, CRNP: Absolutely. My idea of using injections used to be that they were the last resort. If it was, “If you don’t take your medications, you’re in and out of the hospital,” this is almost going to be punitive for them. “You’re at the point where you’re going to have to have an injectable.” I’ve totally changed my perspective on the use of injectables. I see the value in them. I see the value in improving the patient’s quality of life—and the parents’ quality of life if they’re very involved and they have a child who has schizophrenia. There’s that constant fight between the parents and the young adult child to take their medications. I start them on an oral antipsychotic that would have the potential to be converted into a long-acting injectable. I start that conversation early, not just early in my treatment relationship with the patient but also earlier in the course of illness than I ever thought I would see possible.
Sanjai Rao, MD, DFAPA: Do you ever do it with first episodes?
Kimberly Garcia, DNP, CRNP: I do.
Sanjai Rao, MD, DFAPA: So you’re really looking at conversion to LAI, not just because they weren’t doing well on orals, but because you want them on an LAI earlier rather than later as a treatment.
Kimberly Garcia, DNP, CRNP: Yes.
Sanjai Rao, MD, DFAPA: That evolution that you described mirrors the evolution of many of the treatment guidelines that we’ve seen. If you look at the American Psychiatric Association treatment guidelines—the previous set of guidelines, from 10 years ago—they basically said what you said at the beginning. You start oral medications, and you try different oral medications. If the oral medications aren’t working—if the patients are chronically nonadherent, if they have psychosocial or substance abuse problems, or all these other complicating factors—then way down the line you’ll give people a long-acting injectable. Their latest set of guidelines that came out in 2020 says, all those people should still get LAIs, but you can also think about LAIs earlier in the treatment course if the patient prefers to receive an LAI.
Kimberly Garcia, DNP, CRNP: Absolutely.
Sanjai Rao, MD, DFAPA: I looked at this and said, “This is reasonable.” But I wish they’d gone further in the vein than you’ve gone. It’s not just that an LAI is an “if they prefer it” option. Saying if they prefer it or not really requires more along the lines of what you’re doing, which is actively educating the patient on the potential benefits and risks of an LAI—representing the true benefits of an LAI and then seeing if they prefer it. Not just kind of throwing it out there and saying, “Do you want to do this?” There are real reasons to take an LAI that might offer potential benefits over taking an oral.
Transcript edited for clarity.